15050070CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10201 HILLCREST RD
CONTRACTOR: 10 Pe, LJIER PERMIT NO: 15050070
OWNER'S NAME: LORRAINE THOMPSON &TRENT POLTRONET
a -5 7Y7 �i /I DATE ISSUED: 05/12/2015
W
ONER'S PHONE: 6507995009
y�p��G7A G PHONE NO:951- 677. 77fO
❑ LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL ❑
INSTALLATION OF ROOF MOUNTED SOLAR (52
License Class Lt.--Ub Lic. i1
MODULES)(13KW)
Contractor MI6 rGc. TW_ &,61,, ate 5- 1Z — 16
1 hereby affirm that 1 am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
Sq. Ft Floor Area:
Valuation: $60000
performance of the work for which this permit is issued.
have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
APN Number: 32616086.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. I agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
Issued by: 1/✓ ��i Date: �' �t� ��
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
RE -ROOFS:
9.18.
Signature /� /f Date 17
All roofs shall be inspected prior to any roofing material being installed. if a roof is
installed without first obtaining an inspection, 1 agree to remove all new materials for
inspection.
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
1 hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
1 hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(x) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's
material. Additionally, should 1 use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 2550 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
_
Owner or authorized agent: Date:
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Date
CUPERTINO
1.5��ao 70
ALTERNATIVE ENERGY PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(cDcupertino.org
AE
_ 1,
PROJECT ADDRESS 102_0\
APN d
OWNER NAME
�f�cn� hei a
PHONE
650.
E-MAIL
STREET ADDRESS
CITY, STATE, ZIP
to k�lo CA X,561
FAX
CONTACT NAME —
PHONE
E -MAI,_
STREET ADDRESS
CITY, STATE, ZIP
FAX
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT I,� CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CONTRACTOR NAME
t c,�x
LICENSE NUMBER
LICENSE TYPE
BUS. LIC d
r1
�
2,6 — c�
COMPANY NAME
E-MAIL_
��t�
FAX
6 6
G or, F� ►�
STREET ADDRESS
CITY, STAT , ZIP
PHONE,
ARCHITECT/ENGINEER NAME
LICENSE NUMBER
BUS. LIC N
COMPANY NAME
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
USE OF SFD or Duplex ❑ Multi -Family
PROJECT IN WILDLAND
PROJECT iN
STRUCTURE: ❑ Commercial
URBAN INTERFACE AREA ❑ Yes [ NO
FLOOD ZONE ❑ Yes NO
SOLAR PANELS
❑ ELECTRIC VEHICLE CHARGING STATION
I ❑ SOLAR WATER HEATING
❑ OTHER:
FOR SOLAR PANELS: NUMBER OF PANELS/UNITS:� KILOWATTS (COMMERCIAL ONLY):
TOTAL VALUATION:
Fs
(XJd
DESCRIPTION OF WORK
a-
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. 1 have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to building construc n. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
0, i lR C> itsx
CI �
1�,7tPr$S
STArMARD
Cl n��,aroR
PVApp_2011.doe revised 03116111
CITY OF CUPERTINO
FM___7 FEE ESTIMATOR - BUILDING DIVISION
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
nistriet. etc ). These fees are hated on the nrelinunary information available and are only an estimate Contact the Dent for addn 7 info.
FEE ITEMS (Fee Resolution 11-053 Eff 711113)
ADDRESS: 10201 HILLCREST RD
DATE: 05/12/2015
REVIEWED BY: SEAN
Ff ,:h Pcq'ro r/ f Cc"
APN:
BP#:`VALUATION:
Z 2D
$60,000
*PERMIT TYPE: Building Permit
PLAN CHECK TYPE: Alteration / Repair
PRIMARY SFD or DuplexT
USE:
Suppl. PC Fee: Q Reg. Q OT
PENTAMATION SOLAR -RES
PERMIT TYPE:
WORK
INSTALLATION OF ROOF MOUNTED SOLAR 52 MODULES 13k
SCOPE
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
nistriet. etc ). These fees are hated on the nrelinunary information available and are only an estimate Contact the Dent for addn 7 info.
FEE ITEMS (Fee Resolution 11-053 Eff 711113)
FEE
QTY/FEE
MISC ITEMS
Ff ,:h Pcq'ro r/ f Cc"
Ph ,b J"'+m/1 l c_
"cr?lml /'c'
hr�r 1tr,.la. lrrsr>
Jtltcr F'hnr�h / s�',
ILI
Suppl. PC Fee: Q Reg. Q OT
c' -
NOTE: This estimate does not include fees due to other Departments (i.e. Planning, Public Works, Fire, Sanitary Sewer District, School
nistriet. etc ). These fees are hated on the nrelinunary information available and are only an estimate Contact the Dent for addn 7 info.
FEE ITEMS (Fee Resolution 11-053 Eff 711113)
FEE
QTY/FEE
MISC ITEMS
Plan Check Fee:
$0.00
=#
$236.00
Alternative Energy System
IPHOTOVRES Photovoltaic System
Suppl. PC Fee: Q Reg. Q OT
FO.OThrs
$0.00
PME Plan Check:
$0.00
Permit Fee:
$0.00
Suppl. Insp. Fee:Q Reg. Q OT
F0.0Thrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
"r�rr:,'t'r r,ictort 7'�c�:
(c(rr err ,Y6 r rd-� P cc:
0
Work Without Permit? 0 Yes e) No
$0.00
Advanced Plannin Fee:
$0,00
Select a Non -Residential
Building or Structure
0
0
i
7rruv(,1 1)ucTurn c)� Irziioru 1 `�:�:.ti�
Strong Motion Fee: IBSEISMICR
$7.80
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$3.00
$'I;.IBTOTALS:
$10.801
...........
$236.00
1 TOTAL F'EE:
$246.80
Revised: 04/01/2015
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